Q: Why did you decide to examine differences in mortality rates for the leading causes of infant death between rural and urban areas in the United States?

DE: After finding differences in infant mortality rates between rural and urban places in previous work, we thought causes of death might also differ by urbanization level. Although previous research looked at infant mortality rates by age of death and residence, there had not been research on leading causes of infant death by rural-urban status.

Q: Can you describe the differences in infant, neonatal, and postneonatal mortality rates?

DE: Infant mortality rates are based on all infant deaths. Neonatal mortality specifies the infant was less than 28 days of age at time of death and postneonatal mortality rates are those infant deaths that occurred between 28 days and 11 months of age. In this data brief, as in previous research, we see higher neonatal mortality rates than postneonatal mortality rates. Indeed, neonatal mortality rates were nearly twice as high as postneonatal mortality rates across urbanization levels. Further, there are distinct differences in the leading causes of death for neonatal and postneonatal mortality. Although both include congenital malformations, neonatal deaths are generally associated with more birth related medical issues whereas postneonatal deaths are generally associated with more causes external from the infant.

Q: Overall, how did the mortality rate for the five leading causes of infant death vary by urbanization level?

DE: Rural areas have higher infant, neonatal, and postneonatal mortality rates than urban areas. However, when we drill down by the leading causes of death by age of death, there are specific causes of death where infants in rural areas do experience lower mortality rates, such as mortality from low birthweight and from maternal complications. However, there are markedly higher mortality rates for both neonatal and postneonatal infants from congenital malformations, sudden infant death syndrome, and unintentional injuries in rural places than in urban.

Q: Were there any surprises in the findings from this report?

DE: Although we expected differences in mortality rates by the leading causes of death, I think we were surprised by the marked differences for some causes; particularly SIDS mortality rates being twice as high in rural places than in large urban counties. I also think some of the most interesting findings in the report are related to how rural infant mortality rates are generally higher than rates in urban areas, but there are some causes for which rural places have similar or even lower rates compared to urban places.

Q: What is the take home message in this report?

DE: The message that should be taken from this report is that different types of places– rural and urban– have different issues when it comes to the leading causes of infant death. Although the leading causes are generally the same across areas, there are substantial differences in rates, meaning different public health interventions may be needed for people in rural areas compared to people in urban areas to address these issues.

DE: The most significant finding in this study was the consistency with which infants in rural areas have significantly higher mortality rates than infants in urban places. Higher rural infant mortality was generally observed by race and Hispanic origin, mother’s age, and by infant age at death.

DE: Generally, previous research shows that health outcomes are poorer in rural places compared with urban places and this study is consistent with those findings. This study did not examine the factors that might be influencing the higher rural infant mortality in comparison with urban infant mortality.

Q: Is this surprising, or are problems with poverty, substance abuse, and health care that much worse in rural areas?

DE: Higher infant mortality in rural places compared with urban places is not necessarily surprising based on the number of other poor health outcomes (such as higher overall mortality rates, higher rates of disability) that rural residents have in comparison to urban residents.

Q: Are there any theories in the literature as to why this infant mortality disparity exists between rural and urban?

DE: Given there are some poorer health outcomes in rural areas, it is possible more pregnant women in rural areas have poorer general health than pregnant women in urban areas that can lead to poor infant outcomes. Further, there is generally less access to health care due to distance and number of providers available in rural areas, which can impact health outcomes.

Q: Any other findings of note that you find significant?

DE: These findings highlight the importance of place for infant survival and suggests the need for including place in research on health outcomes, as well as a need for further research on the greater risk of infant death in rural settings.

Q: Are teen birth rates in the U.S. higher in urban areas or rural areas?

BH: The birth rate for teenagers is higher in rural areas than in urban areas. In 2015, the rate was 30.9 births per 1,000 females aged 15-19 for rural areas compared with 20.9 for urban areas. This difference persisted over the duration of the study, from 2007 through 2015, and was seen in the teen birth rates for non-Hispanic white, non-Hispanic black, and Hispanic females.

Q: What explains the differences or similarities in the two areas?

BH: The data on which the report is based comes from the birth certificates filed in all states and DC. While the data from the birth certificate provide detailed information on a number of topics, this report did not examine reasons for urban/rural differences, as information on many contributing factors is not available from the birth certificate.

However, the report shows that while the birth rate for teenagers is higher in rural areas than in urban areas, birth rates for all areas declined from 2007 through 2015, down 50% in large urban, 44% in medium and small urban, and 37% in rural areas.

Q: What were some of the regional differences you observed in teen birth rates in urban or rural areas?

BH: The urban teen birth rate declined for all states and DC between 2007 and 2015, with declines ranging from 24% for teens in North Dakota to 57% for teens in Arizona, whereas the rural teen birth rate declined for in nearly all states, with declines ranging from 18% for teens in Alaska to 73% for teens in Connecticut.

Among the urban areas, states with the largest declines (50% or more in the teen birth rate) include: Arizona, California, Colorado, Connecticut, Florida, Georgia, Maryland, Massachusetts, Minnesota, Mississippi, New Jersey, New Mexico, North Carolina, Rhode Island, Utah, Vermont, and Virginia.

Among the rural areas, states with the largest declines (50% or more in the teen birth rate) include: Colorado and Connecticut.

Q: Are there any data which suggests sexual activity among teens is higher in urban vs. rural areas – or vice versa?

BH: As noted, information is not available from the birth certificate on the attitudes and behavior of the parents associated with fertility and family formation.

Q: What are the differences in teen birth rates among race/ethnic groups and are there different patterns among these groups depending on whether they live in urban or rural areas?

BH: Teen birth rates for non-Hispanic white, non-Hispanic black, and Hispanic females were highest in rural counties and lowest in large urban areas in 2015.

For each area, the teen birth rate was consistently highest for Hispanic females and consistently lowest for non-Hispanic white females.

The difference in the teen birth rate between rural and large urban areas was lowest for non-Hispanic black females and greatest for non-Hispanic white females.

Q: Which U.S. counties have the highest teen birth rate and which counties have the lowest?

A: Teen birth rates are not available for individual counties in the report. Counties are grouped into areas according to their urban or rural designation and the teen birth rate was reported for an area based on the aggregated data of the counties for the area.